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Developed by: Toronto Best Practice in LTC Initiative
December 2006
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Toronto Best Practice Implementation Steering Committee
Helen Ferley, Co-Chair Administrator Seniors’ Health Centre – North York General Hospital
Patty Carnegy, Co-Chair Staff Education Coordinator Toronto Homes for the Aged
Carolyn Acton Manager, Client Services Toronto Community Care Access Centre
Sue Bailey Psychogeriatric Resource Consultant Providence Healthcare
Janice Buchanan Mental Health and Addiction Consultant Ministry of Health and Long-Term Care Toronto Regional Office
Martha Burnside Director of Care Yorkview Lifecare
Glenn Dudman LTC Program Consultant Ministry of Health and Long-Term Care Community Health Division
Gabriella Golea Administrative Director Geriatric Mental Health and Dual Diagnosis Programs Centre for Addiction and Mental Health Metzie Lacroxi Director of Nursing Lincoln Place
Becky Li Director of Resident Care Mon Sheong Foundation Penelope Minor Nurse Manager/Clinical Coach Baycrest Vania Sakelaris LTC Program Consultant Ministry of Health and Long-Term Care Community Health Division
Josephine Santos Regional Best Practice Coordinator, Long-Term Care – Toronto Region Ministry of Health and Long-Term Care Host Agency: Seniors’ Health Centre – North York General Hospital Nada Simic Nurse Manager Castleview Wychwood Tower Anne Stephens Clinical Nurse Specialist in Gerontology St. Michael's Hospital Cindy Stephens Director of Nursing Cummer Lodge Clara Tsang Geriatric Clinical Nurse Specialist/ Nurse Practitioner Rouge Valley Health System Geriatric Emergency Management
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Acknowledgments This policy and procedure was developed by the Toronto Bladder and Bowel Best Practice Long-Term Care Working Group:
Helen Alemany Clinical Practice Leader, Villa Colombo Brenda Braganca Director of Care, Lakeside Long-Term Care Centre Shelly Gorchynski Education Consultant, The Wexford Lorna Hedger Assistant Director of Care, Lakeside Long-Term Care Centre Yasmin Merali Extendicare LTC Consultant Susee Nadlarajah Assistant Director of Care, Hellenic Home Frances Nelson Staff Registered Nurse, West Park Long Term-Care Centre
Josephine Santos Regional Best Practice Coordinator, Long-Term Care – Toronto Region Ministry of Health and Long-Term Care Host Agency: Seniors’ Health Centre – North York General Hospital
The Toronto Best Practice Implementation Steering Committee has reviewed this policy and procedure and would also like to thank all the stakeholders who participated in the review process.
The Best Practice in Long-Term Care Initiative is funded by the Ontario Ministry of Health and Long-Term Care.
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Table of Contents Policy 5 Purpose 5 Preamble 5 Team Members – Roles and Responsibilities 5 Procedure A – Bladder and Bowel Continence Assessment B – Care Planning C – Interventions Based on Urinary Incontinence Types D – Interventions to Promote Urinary Continence E – Interventions for Residents with Intractable Incontinence F – Interventions to Prevent and Manage Constipation References Appendix A Bladder and Bowel Continence Assessment Appendix B Quarterly Continence Assessment Appendix C Voiding/Fluid Record Appendix D 7-Day Bowel Record Appendix E Classification of Laxative Therapies Appendix F Stepwise Approach to Management of Constipation Appendix G Glossary of Terms
7 7 8 8 13 14 16 17 21 22 23 24 25 26
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Disclaimer: This policy and procedure has been developed by a group of LTC Homes and the Regional Best Practice Coordinator in Toronto. It is based on the 2005 Ministry of Health and Long-Term Care Standards on Continence Care and the RNAO Best Practice Guidelines on Promoting Continence Using Prompted Voiding and Prevention of Constipation in the Older Adult Population, and other best practice sources on the same topics. It has been reviewed by stakeholders from various LTC Homes and representatives of the Toronto Best Practice Implementation Steering Committee. This policy and procedure is to be used as a guideline at the discretion of the LTC Homes. POLICY: Each resident must be assessed for bladder and bowel functioning within 7 days of admission, quarterly and any change in condition that affects continence. PURPOSE: The purpose of the bladder and bowel management program is to: 1. Address resident’s individual needs with respect to continence of the bladder and bowel. 2. Initiate appropriate strategies and interventions. 3. Provide learning opportunities. 4. Monitor and evaluate resident outcome PREAMBLE: The interdisciplinary team plays a significant role in bladder and bowel management, promotes open communication and monitors the outcome of the program. A continence team may be established to provide expertise with assessment for incontinence, the promotion of continence, the proper use of continence-care products, appropriate toileting routines, and to ensure the Continence program is being managed effectively for all residents.
Team Members Roles and Responsibilities Director of Care or Designate
• Facilitates the implementation of bladder and bowel management procedures for each individual resident including education.
• Collects data, analyzes statistics, identifies trends, evaluates outcomes and presents quarterly statistics to an interdisciplinary committee.
• Seeks advice from experts such as Nurse Continence Advisors including suppliers to support team decisions.
• Coordinates education processes relating to bladder and bowel management.
• Ensures equipment and supplies are adequate for resident’s needs. Nursing (RN and RPN) • Completes a bladder and bowel continence assessment within 7 days
of admission, quarterly and any change in condition that affects continence.
• Initiates and communicates a plan of care to address the resident’s bladder and bowel issues.
• Makes referral to other interdisciplinary team members.
POLICY AND PROCEDURE
BLADDER AND BOWEL MANAGEMENT
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Team Members Roles and Responsibilities Nursing (RN and RPN) • Provides education to family/resident about bladder and bowel
management. • Evaluates the plan of care and updates as necessary. • Assesses Health Care Aide/Personal Support Worker skills and
encourages staff development, e.g., transfer skills. • Reviews bladder and bowel record and addresses constipation with
interdisciplinary team. • Responds to Health Care Aide/Personal Support Worker’s
assessment, re. bladder and bowel management concerns. Health Care Aide/Personal Support Worker
• Offers privacy and develop rapport with resident when toileting/changing.
• Encourages fluid and nutritional intake, e.g., 1500 ml of fluid daily. • Follows procedure and care plan to promote continence. • Assists residents when transferring, ambulating or walking to the toilet. • Maximizes mobility and passive exercises. • Toilets the residents prior to bathing and as per care plan. • Completes the voiding and bowel record and reports concerns or
changes to the RN/RPN. • Recognizes and reports resident verbalizations and behaviours
indicative of discomfort. • Reports any signs and symptoms of bladder and bowel discomfort to
the RN. Occupational Therapist (OT)/ Physiotherapist (PT)
• Assesses, develops a treatment plan and implements rehabilitative/ restorative/maintenance balance and mobility interventions; communicates treatment plan to interdisciplinary team.
• Advises staff on transferring techniques. • Assesses and recommends assistive equipment, such as wheelchairs,
walkers, and canes. • Educates residents, family and staff on how to use equipment safely. • Evaluates and reassesses resident status.
OT Assistant /PT Assistant/Rehabilitation Assistant
• Carries out the rehabilitative/restorative/maintenance balance and mobility treatment plan.
• Monitors resident responses and reports responses to OT/PT & interdisciplinary team.
• Monitors/inspects assistive equipment, such as wheelchairs, walkers, and canes on a regular basis.
Registered Dietitian • Completes nutritional risk assessment within 7 days. • Orders appropriate diet and supplements as described by the LTC
Homes policy. A Physician co-signature is required. • Makes recommendations to Physicians. • Suggests fluid and nutritional intake to reduce possibility of
constipation. Recreation Therapist/Restorative
• Involves the resident in group or one to one exercise, range of motion, social programs.
• Recognizes and reports resident verbalizations and behaviours indicative of discomfort.
• Helps resident to toileting if needed during program. • Reports resident changes to RN.
Physician • Identifies and implements medical interventions to address bladder and bowel symptoms.
• Takes into consideration the recommendations of Pharmacists and Dietitians.
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Team Members Roles and Responsibilities Social Work • Provides support to resident’s psychosocial needs.
• Counsels and supports families as needed. Pharmacist • Reviews medications and supplements.
• Provides consultation services. • Provides education.
Podiatrist/Chiropodist • Assesses for nail care and advices for the prescription of appropriate footwear for the resident’s individual needs.
Chaplain • Provides support to resident’s spiritual/cultural needs. • Counsels and supports families.
Maintenance/Housekeeping • Supports a clean and odour-free environment. • Maintains a comfortable environmental temperature.
Family/Resident • Provides information on bladder and bowel habits to staff. • Attends the multidisciplinary conference. • Works with staff and resident to support plan of care.
PROCEDURE: A. Bladder and Bowel Continence Assessment The interdisciplinary team will: 1. Conduct and document a bladder and bowel continence assessment,
• Within 7 days of admission. • Following any change in condition that affects continence. • With quarterly documentation.
B. Care Planning The interdisciplinary team will: 1. Initiate a written plan of care upon completion of the bladder and bowel continence assessment and
update as necessary. 2. Promote the independence and dignity of continent residents by:
• Providing orientation to bathroom locations. • Assisting as required.
3. Develop an individualized toileting routine for each individual resident. 4. Ensure that all residents, where possible, are toileted e.g., toilet incontinent residents. 5. Assess residents who require continence care products for proper product fit, using supplier
guidelines. (Refer to Interventions for Residents with Intractable Incontinence). 6. Reassess and evaluate the effectiveness of the resident’s continence care plan on a quarterly basis. 7. Educate staff, resident and families on continence/incontinence care. 8. Take any or all of the following actions when there is a change in health status that affects
continence: • Use a voiding record for 3 days if the resident demonstrates a change in voiding patterns or
abnormal bladder control. • Identify contributing factors and the type of urinary incontinence. • Develop a written plan of care. • Evaluate and document resident outcome.
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• Reassess as required for any further change in resident’s health status that affects continence and refer to appropriate interdisciplinary team members as necessary.
C. Interventions Based on Urinary Incontinence Types
The interdisciplinary team will: 1. Follow the table below for interventions based on urinary incontinence types.
Stress UI Urge UI Overflow UI Functional UI Cause Failure to store Failure to store Failure to empty Failure to store Frequency 20% of all cases 50% of all cases 10% of all cases 20% of all cases Symptoms • Small amount
of urine loss frequently when residents coughs, laughs,
changes position • Wet during day • Dry at night, no
distention
• Large amounts of urine loss frequently “can’t get to bathroom in time”
• Wet day and night • No distention
• Small amounts of urine loss frequently
• Wet day and night • Distention
• Bladder and sphincter are normal
• Wet day and night • No distention
Pathology Weakness of sphincter
Result of neurological and/or urological disease
• Female: result of cystocele
• Male: result of enlarged prostrate, fecal impaction
Other factors cause incontinence: • Drugs • Environment • Psychological
Prevalence Mostly female Both male and female Both male and female Both male and female Treatments/ Interventions
• Medications (e.g., Premarin & Entex-LA)
• Kegel exercises*
• Prompted voiding*
• Medications (e.g., Ditropan & antibiotics)
• Surgery • Bladder retraining
routines* • Toileting routines* • Prompted voiding*
• Medications (e.g., Prazosin & Proscar)
• Surgery • Double voiding* • Crede maneuver* • Bowel
maintenance program**
• Disimpaction
• Medications • Surgery • Environment • Mobility • Psychological • Prompted voiding*
*See details under Section D: Interventions to Promote Continence. **See details under Section F: Interventions to Prevent and Manage Constipation. Note: See Appendix A for Critical Pathway for Urinary Incontinence D. Interventions to Promote Urinary Continenc e Strategies/Approaches Bladder Retraining Routines
Description Bladder retraining programs are most ap propriate for residents with urge urinary incontinence. It includes techniques to suppress precipitancy and the use of scheduled voiding to restore normal bladder function or to improve continence.
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Strategies/Approaches Description Bladder retraining programs are most effective for residents who are:
• alert; • can fully understand; • can communicate with their care providers; and • able to follow instructions given to them.
The resident must have adequate cognitive functioning to indicate when he/she has to go to the bathroom. A 3 to 4 hour toileting schedule can generally be established within 4 to 6 weeks from the time that the program is initiated.
Bladder Retraining Routines
Interventions The interdisciplinary team will: 1. Ensure that all contributing factors (e.g., medications, disease)
and functional limitations (e.g., strength for standing and transferring) have been assessed and corrected.
1. Determine, from the voiding study, the period of time that the
resident usually holds his/her urine before voiding (i.e., if the resident only holds urine for a half hour, toileting should begin at quarter hour intervals).
2. Explain the program to the resident in simple language. 3. Toilet the resident at the determined interval for one week. If the
resident’s voiding pattern cannot be clearly identified, start the toileting interval every two hours.
4. Leave the resident on the toilet a maximum of five minutes. 5. Increase the toileting interval by 15 minutes at the end of week
one. 6. Give the resident positive feedback each time the resident holds
urine for the correct amount of time. If the resident cannot hold the urine, encourage him/her to try again.
7. Gradually increase the interval between voiding by 15 minutes
each week until the resident can hold the urine for a 4-hour period.
Prompted Voiding Description Prompted voiding is a behavioural intervention used to treat
residents with stress, urge and functional urinary incontinence.
Note, however, that it is the care provider’s response that changes, and not that of the incontinent individual. The caregiver is expected to intervene prior to the undesired bladder voiding rather than rely on an incontinence aid or clothing.
Prompted voiding is used most effectively for the treatment of urinary incontinence in persons with physical and/or cognitive deficits, who will respond to timely reminders from caregivers.
The best predictor of an individual’s response to prompted voiding will be his or her success to a therapeutic trial.
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Strategies/Approaches Description The 3 primary techniques of prompted voiding are monitoring,
prompting and praising:
Monitoring involves asking the incontinent individual if he or she needs to use the toilet at regular intervals. The interval, however, will not always be timed by the clock. The caregiver should also respond to behavioural indicators (restlessness, agitation, disrobing) that suggest the resident may need to use the toilet. In such cases, the ‘regular interval’ for prompting may have to coincide with the individual’s personal schedule.
Prompting a person to use the toilet at regular intervals encourages the maintenance of bladder control between prompted voiding sessions.
Praising is positive reinforcement given by the staff for dryness and maintaining bladder control.
Prompted Voiding
Interventions Before Initiating Prompted Voiding The interdisciplinary team will: 1. Determine the resident’s pattern of incontinence using a 3-day
voiding record before initiating prompted voiding.
1. Address constipation and fecal impaction.
2. Encourage fluid intake of 1500 ml/day.
3. Minimize caffeinated and alcoholic beverages where possible.
4. Initiate an individualized prompted voiding schedule based on the resident’s toileting needs, and as indicated by the 3-day voiding record.
5. Initiate another 3-day voiding record between 3 and 8 weeks after the prompted voiding schedule begins.
6. Determine the success of the prompted voiding trial and develop the plan of care based on the results.
7. Evaluate and document resident outcome.
Calculation: To determine the success of the prompted voiding trial, calculate the number of times toileting was successful, and divide the total number of toileting attempts and multiply by 100. • Residents who show a poor ability to toilet using this method (less
than 49% successful attempts), and who do no express a desire to be either changed or toileted, should be treated as incontinent and cared for using appropriate incontinence products and changing schedules.
• Research indicates that residents who respond well to prompted voiding can be identified with a high degree of accuracy during a 3-day trial of intervention. Residents who achieve a wet rate of 20% or less or an appropriate toileting higher than 66% should continue to undergo prompted voiding. Residents who do not meet either of these criteria should be considered for further urinary evaluation such as urodynamic tests.
• Research also shows that prompted voiding is not successful during the night, especially between one am (0100) and (0400) four a.m.
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Strategies/Approaches
Prompted Voiding Interventions Prompted Voiding Procedure The interdisciplinary team will: 1. Contact the resident every two hours during the day.
2. Focus the resident’s attention on voiding by asking whether he or she is wet or dry.
3. Check resident for wetness and give feedback on whether the resident’s self-report was correct or incorrect.
4. Ask the resident if he or she would like to use the toilet whether resident is wet or dry.
5. Assist resident with toileting.
6. Record the results on the voiding record.
7. Give the resident positive reinforcement by spending an extra minute or two conversing with him or her.
8. Repeat the request if the resident does not want to use the toilet and has not attempted to void in the last four hours, and assist him/her if an affirmative response is received.
9. Inform the resident that they will be back in two hours and request that the resident try to delay voiding until then.
10. Change the resident if he/she is wet and declines to use the toilet.
11. Record the results of each check and toileting attempt on the voiding record.
Description Toileting routine is most appropriate f or residents with urge urinary incontinence.
An individualized toileting routine can be established for residents who have the ability to be toileted, as determined by a continence assessment and prompted voiding trial.
Purpose of a toileting routine:
• Restore a normal pattern of voiding
• Reduce incontinent episodes
• Provide for resident comfort
• Hygiene
• Safety
• Increased self-esteem
• Prevent skin breakdown
Toileting Routines
Interventions The interdisciplinary team will:
1. Assist resident to transfer to toilet or commode using safe transfer techniques.
2. Position the resident to provide adequate support for feet and body as needed.
3. Provide privacy while remaining in the immediate area to ensure
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Strategies/Approaches
Toileting Routines Interventions safety.
4. Ensure that any resident requiring support in sitting position is not left unattended. Restraint is not to be used while resident is using a toilet or a commode chair.
5. Allow resident 5 minutes to void.
6. Provide peri-care as required.
7. Assist resident to rearrange clothing as necessary.
8. Allow resident to wash hands.
9. Wash their own hands thoroughly.
10. Assist resident to return to comfortable position.
11. Support and reassure resident to achieve success in toileting routine.
12. Toilet the resident at the following times based on the individual resident’s pattern.
• Upon awakening in the morning
• After breakfast
• Before or after lunch
• Before or after supper
• At bedtime
• During the night if resident is awake
13. Assist as requested by resident.
Description Kegel exercises are most appropriate fo r residents with stress urinary incontinence.
They are designed to strengthen the muscles of the pelvic floor, which improves function of the urethral and rectal sphincter muscles.
Kegel Exercise
Interventions The interdisciplinary team will: 1. Teach resident Kegel exercises to strengthen muscles of the
pelvic floor: • Seat resident on toilet and instruct to initiate voiding. • Once flow has been initiated, have resident stop by contracting muscles. • Hold flow to count of three. • Gradually increase the number of contractions to 10-20 times
per exercise. Description Double voiding is most appropriate for overflow uri nary
incontinence. It involves reinitiating the voiding reflex a minute or two after the resident has finished voiding. It offers the bladder a second opportunity to contract and expel urine.
Double Voiding
Interventions The interdisciplinary team will: 1. Perform techniques to trigger voiding such as running water and
stroking the inner thigh or base of the spine to stimulate voiding reflex.
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Strategies/Approaches Description Crede maneuver is most appropriate for overflow urinary
incontinence. It facilitates bladder emptying through external bladder manual bladder compression. This is done after voiding, or during voiding, to assist urine drainage.
Crede Maneuver
Interventions The interdisciplinary team will: 1. Instruct the resident to elevate his/her feet on a footstool and lean
forward slightly during voiding to increase intra-abdominal pressure and facilitate bladder emptying.
E. Interventions for Residents with Intractable Inc ontinence Type of Urinary Incontinence
Description Residents identified as having intractable incontinence are those who have been assessed, have had contributing factors identified, and for whom attempts at regaining continence have not been successful.
Intractable Incontinence
Interventions
The interdisciplinary team will: 1. Assess the need for a continence-care product at the time of
admission and re-evaluate with documented change in continence status.
• If a continence-care product is required, the resident should be measured to determine the appropriate size and evaluated for the most effective category of product according to their level of incontinence.
• An adequate supply and usage of products, in a range of absorbencies and sizes, should be stocked.
• Develop a system to monitor product usage and effectiveness.
2. Check incontinent residents frequently and change as necessary based on product manufacturer’s recommendation, such as:
• Upon awakening
• After breakfast
• After morning nourishment
• After lunch
• After afternoon nourishment before supper
• After supper, at bedtime
• Last rounds
• Twice during the night
3. Provide peri care and skin care when changing the incontinence product.
4. Assess the perineum for redness and skin breakdown and follow the LTC Homes’ own policy and procedure on skin care.
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Type of Urinary Incontinence
Intractable Incontinence
Interventions
5. Document the frequency of changes and bowel movements on the resident’s daily care flow sheet.
6. Update the care plan quarterly or when there is a change in condition that affects continence.
F. Interventions to Prevent and Manage Constipation Strategies/Approaches
Description Bowel management involves promoting regular, voluntary, controlled bowel evacuations of normal consistency. Normal bowel function involves passage of soft, formed stools in adequate volumes without straining.
Preventive Measures for Residents At Risk of Constipation
Interventions The interdisciplinary team will: 1. Determine the resident’s bowel using a 7-day bowel record before
initiating a constipation protocol.
2. Encourage intake of a minimum of 1500 ml of fluid every 24 hours, unless it is contraindicated for a particular individual and whenever possible, minimize caffeinated and alcoholic beverages.
3. Provide an adequate amount of fiber in the resident’s daily diet in consultation with a dietitian.
4. Promote a regular pattern of toileting at the same time each day, based on the resident’s triggering meal.
5. Assist the resident into a squat position to facilitate the defecation process.
6. Encourage physical activity based on the resident’s abilities and health condition.
7. Evaluate the resident’s response to interventions through the use of a bowel record. It should document frequency, character and amount, bowel movement pattern, episodes of constipation/fecal soiling and use of oral and rectal laxative interventions.
8. Respond in a timely way to the resident’s urge to defecate usually after the triggering meal.
9. Provide education regarding the promotion of bowel health to all who are involved – health care providers, residents, family or caregivers.
10. Evaluate the success of preventive measure by using a 7 day bowel record.
Routine Bowel Protocol
Description The purpose of a routine bowel protocol is to facilitate early identification of constipation (as indicated by individual resident bowel patterns and as documented on a bowel record), and to reduce episodes of constipation.
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Strategies/Approaches
Description Contraindications:
Do not apply a routine bowel protocol if:
• There is blood in the resident’s stool.
• There is a significant change in the resident’s mental status.
• Bowel sounds are not heard on assessment.
• An abdominal mass of unknown origin is palpated.
Routine Bowel Protocol
Interventions The interdisciplinary will:
1. Consider the following before implementing a routine bowel protocol:
• Documentation on recent bowel records.
• Assessment for abdominal distension, presence of bowel sounds, rectal examination.
• Contributing factors and management of them.
• Changes in medications, food or fluid intake, activity levels, emotional status
2. Consult the dietitian and contact a physician for implementation of a bowel protocol.
3. Avoid reoccurrence through follow-up on strategies with the physician and/or the dietitian.
• Note: See Appendix E for the Classification of Laxative Therapies and Appendix F for a Stepwise Approach to Management of Constipation.
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References: Folden, S., Backer, J. H., Maynard, F., Stevens, K., Gilbride, J. A., Pires, M., & Jones, K. (2002). Practice guidelines for the management of constipation in adults. Rehabilitation Nursing Foundation. [On-line]. Available: http://www.rehabnurse.org/profresources/BowelGuidefor WEB.pdf. IC 5: Improving Continence Care in Complex Continuing Care Hospitals. [On-line]. Available: www.hospitalreport.ca/projects/QI_projects/IC5.html Ministry of Health and Long-Term Care. (2005). Standards: Continence Care. Toronto, Canada: Ministry of Health and Long-Term Care. Ontario Association of Non-Profit Homes and Services for Seniors. (2005). A Resource Guide for Long Term Care Homes: Skin and Wound Care, Continence Care, Nutrition and Hydration. Woodbridge, Canada: Ontario Association of Non-Profit Homes and Services for Seniors. Ouslander, J. G., Schnelle, F. J., Uman, G., Fingold, S., Nigam, G. J., Tuico, E., & Jensen, B. B. (1995). Predictors of successful prompted voiding among incontinent nursing home residents. Journal of the American Medical Association, 273(17), 1366-1370. Registered Nurses’ Association of Ontario. (2005). Orientation Program for Nurses in Long-Term Care Workbook. Toronto, Canada: Registered Nurses’ Association of Ontario. Registered Nurses’ Association of Ontario. (2005). Prevention of Constipation in the Older Adult Population. (Revised). Toronto, Canada: Registered Nurses’ Association of Ontario. [On-line]. Available: www.rnao.org/bestpractices Registered Nurses’ Association of Ontario. (2005). Promoting Continence Using Prompted Voiding. (Revised). Toronto, Canada: Registered Nurses’ Association of Ontario. [On-line]. Available: www.rnao.org/bestpractices Sanburg, A., L., McGuire, T. M., & Lee, T. (1996). Stepping out of constipation: An educational campaign. Australian Journal of Hospital Pharmacy, 26, 350-355. Tramonte, S. M., Brand, M. B., Mulrow, C. D., Amato, M. G., O’Keefe, M. E., & Ramirez, G. (1997). The treatment of chronic constipation in adults. A systematic review. Journal of General Internal Medicine, 12(1), p. 17. University of North Carolina-Chapel Hill School of Medicine, Program on Aging & the Division of Social Services, State of North Carolina. Bladder Management and Adult Care Home. [On-line]. Available: http://www.med.unc.edu/aging/documents/NursingMaterials.pdf
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APPENDIX A: Bladder & Bowel Continence Assessment Date Assessment Initiated: ___________________ Information Source (please circle) – Resident (R), Family (F) _____________, Chart (C), RN, RPN, PSW, other. A. RELEVANT MEDICAL &/OR SURGICAL CONDITIONS (From Resident, Family, Chart)
1 Immobility Issues 1 Cognitive Problems
1 Arthritis 1 Dementia
1 Other________________ 1 Other___________________
1 Neurological Conditions 1 Genito-Urinary (GU) Problems
1 Stroke 1 Recurrent Urinary Tract Infections
1 Parkinson’s Disease 1 Previous G/U Surgery or Injury
1 Multiple Sclerosis 1 Prostate Problems
1 Spinal Cord injury 1 Other___________________
1 Other_____________ 1 Gastro-Intestinal (GI) Problems
1Medical Conditions 1 Chronic constipation
1 Diabetes 1 Diverticular disease
1 Hypertension 1 Hemorrhoids/fissures
1 Hypothyroidism 1 Previous colon surgery
1 Heart Problems 1 Irritable bowel syndrome
Weight : ___________ (kg) 1 Other___________________ B. MEDICATIONS
See over Y N Comments
Antacids with aluminum
Analgesics/NSAIDS
Anticholinergic/ Antispasmodic/ Anti-emetics
Antidepressants
Antihistamines
Anti-hypertensives
Anti-Parkinson agents
Anti-psychotics
Calcium Channel Blockers
Cholinergic
Diuretic
Histamine-2 blockers
Iron supplements
Laxatives
Narcotic analgesic
Sedative/hypnotic
Other
C. URINARY CONTINENCE HISTORY
Urinary Incontinence (UI) Frequency and Timing
1 No daytime UI
1 Once a day or less
1 1-2 times a day
1 3 times a day or more
1 Nighttime only
1 Both day and night UI
Urinary Incontinence Pattern
Urinary Incontinence (UI) Volume
1 Entire bladder contents: large volume
1 Small volume: leaks, drips, spurts
1 Continuous bladder leakage
1 Unable to determine
Onset 1 Sudden
1 Gradual
Duration 1 < 6 months
1 6 months – 1 year
1 > 1 year
1 Unknown
Urinary Incontinence History
Symptoms over the past 6 months
1 Worsening
1 Stable
1 Improving
1 Fluctuating
1 Unknown
Has a physician been consulted with above urinary problems? 1 Yes 1 No
D: SYMPTOMS ASSOCIATED WITH URINARY INCONTINENCE
Type of Urinary Incontinence
Symptoms Y N N/A *Total number of “yes” answers
Leakage with cough, sneeze, physical activity
UI in small amounts (drops, spurts)
UI during daytime only
Stress UI
Fecal incontinence may be present
Strong, uncontrolled urge prior to UI
UI moderate/large volume (gush)
Frequency of urination
Nocturia > 2 times
Urge UI
Nocturnal enuresis – bedwetting
Difficulty starting urine stream or straining to void
Weak or stop/go stream
Post-void dribbling
Prolonged voiding
Fullness after voiding
Suprapubic pressure and pain
Overflow UI
Spurt of urine with movement
Limited mobility
Requires assistance with toileting
Assistive aids/devices required (e.g., mechanical lift, 1-2 staff to assist, high seat, commode, support bars, hand rail, etc.)
Unable to get to the toilet on time/toilet too far
Can’t hold urinal or sit on toilet
Can’t reach/use call bell
Restraints or gerichair
Poor vision
Altered mental status
Pain poorly managed
Functional UI
Can’t manage clothing
*Follow interventions for the type of urinary incontinence that has the most “yes” answers. Take note that mixed incontinence (feature of both stress and urge incontinence) may be possible and interventions should focus on both types of incontinence. Refer to Physician and/or Nurse Continence Advisor for complex urinary incontinence issues.
Addressograph
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Drugs that affect Bowel/Bladder Control
The purpose of this list is to give examples of drugs that can affect incontinence. It is not a comprehensive list. Blood pressure/Heart Anti-hypertensives (Postural hypotension leads and functional urinary incontinence). ACE inhibitors - Benazepril - Captopril - Enalapril - Fosinopril - Lisinopril - Quinapril - Ramipril ACE II inhibitors (ARB’s) - Candesartan - Eprosartan - Irbesartan - Losartan - Telmisartan - Valsartan
Alpha Adreneurgics - Clonidine Diuretics (Diruresis causes overflow incontinence) - Acetazolamide - Amiloride - Bumetanide - Chlorthalidone - Hydrochlorothiazide indapamide - Metolazone - Spironolactone Calcium Channel Blockers (Constipation, diarrhea) - Amlodipine - Diltiazem - Felodipine - Nifedipine - Verapamil Digestion/Excretion: Antacids with aluminum (laxative effect, can cause diarrhea or loose stools)
-Various Alumina compounds
-Aluminum Hydroxide -Calcium Carbonate -Calcium Carbonate and Magnesia -Calcium Carbonate, Magnesia, and Simethicone -Calcium and Magnesium Carbonates -Magaldrate -Magaldrate and Simethicone -Magnesium Carbonate and Sodium Bicarbonate -Magnesium Hydroxide Laxatives (Diarrhea, intestinal cramping, fecal incontinence) - Polycarbophil - Psyllium; Hydrophilic Mucilloid and Senna - Lactulose - Polyethylene glycol 3350 - Magnesium Citrate - Magnesium Hydroxide (Milk of magnesia) - Magnesium Sulfate - Sodium Phosphate - Milk of Magnesia & Mineral Oil - Mineral Oil - Bisacodyl - Cascara Sagrada; and Aloe; and Bisacodyl - Castor Oil - Senna - Sennosides - Bisacodyl and Docusate - Casanthranol and Docusate - Danthron and Docusate - Sennosides and Docusate - Docusate Mood/Behaviour: Antidepressant (Constipation, especially in elderly. Contributes to overflow and functional urinary incontinence. Problems with urination and loss of bladder control. Monoamine oxidase inhibitors (MAO’s) can cause urinary retention.) Tricyclic antidepressants - Amitriptyline - Clomipramine - Desipramine - Doxepin - Imipramine - Maprotiline (tetracyclic) - Nortriptyline
Protriptyline - Trimipramine MAO Antidepressants - Amoxapine - Bupropion - Citalopram - Fluoxetine - Fluvoxamine - Mirtazapine - Nefazadone - Paroxetine - Sertraline - Trazodone - Venlafaxine Anti-psychotics (Constipation, confusion, sedation, rigidity and immobility leading to overflow and functional urinary incontinence).
- Chlorpromazine - Clozapine* - Fluphenazine - Haloperidol - Loxapine - Olanzapine* - Perphenazine - Pimozide - Quetiapine* - Risperidone* - Thioridazine - Trifluoperazine *atypicals Sedative/Hypnotic/ Barbiturate (Can cause excessive sedation and decreased mobility in elderly people predisposing them to functional urinary incontinence. Not commonly used in long term care.)
- Butabarbital Pain; Analgesics Narcotic Constipation and confusion leading to overflow and functional urinary incontinence. - Codeine - Hydrocodone - Hydromorphone - Levorphanol - Meperidine - Morphine - Oxycodone - Pentazocine
- Propoxyphene - Nalbuphine NSAIDS -Urinary retention in elderly and or arthritic patients (on large doses) Oral - Diclofenac - Diflunisal - Etodolac - Fenoprofen - Floctafenine - Ibuprofen - Indomethacin - Ketoprofen - Meclofenamate - Mefenamic Acid - Nabumetone - Naproxen - Oxaprozin - Piroxicam - Sulindac - Tenoxicam - Tiaprofenic Acid -Tolmetin Other Anticholinergic/ Antispasmodic/ Anti-emetics (Constipation and urinary retention leading to overflow and functional urinary incontinence) - Benztropine - Oxybutynin - Procyclidine - Scopolamine - Tolterodine - Trihexyphenidyl 1st Generation Antihistamines - Chorpheniramine - Dephenhydramine - Dimenhydrinate - Hydroxyxine Cholinergic (Cause urge incontinence due to bladder relaxation. Not commonly used in long term care). - Bethanechol Anti-Parkinson agents (Constipation, diarrhea) - Levadopa - Carbadopa - Pergolide
Sources: AHCPR. 2006. Urinary Incontinence. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.section.10079.; Brigham & Women’s Hospital. 2004, Urinary incontinence http://www.brighamandwomens.org/medical/HandbookArticles/Urinaryincontinence.pdf.; The Hartford Institute for Geriatric Nursing. 2001. Urinary incontinence. http://www.hartfordign.org/publications/trythis/issue11.pdf.; IC-5 Continence Project, 2005, http://www.hospitalreport.ca/projects/QI_projects/IC5.html. Rehabilitation Nursing Foundation. 2002. Constipation. www.rehabnurse.org.; RNAO. 2005, Preventing Constipation; Prompting Continence. http://www.rnao.org/bestpractices. ; Royal Women’s Hospital . 2005. Urinary incontinence, http://www.rwh.org.au/rwhcpg/womenshealth.cfm?doc_id=3661. ; Singapore Ministry of Health . 2003, http://www.moh.gov.sg/cmaweb/attachments/publication/Nursing_Management_of_Patients_with_Urinary_Incontinence_1-2003.pdf. U.S. National Library of Medicine and U.S. National Institute of Health . 2006. Drugs, supplements. < http://www.nlm.nih.gov/medlineplus/druginformation.html>.
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E. BOWEL CONTINENCE HISTORY
Bowel Pattern Comments
1 Normal
1 Constipation
1 Diarrhea
1 Fecal incontinence
1 Irritable bowel pattern
1 Impaction
1 Laxative use/ suppositories/enemas – type and frequency: ________________
1 Other remedies used to help with bowel movement: __________________
Frequency: Usual time of day: Triggering meal: Nature & consistency: Other factors that have caused loss of bowel control:
Has a physician been consulted with above bowel problems? 1 Yes 1 No
F. MISCELLANEOUS RISK FACTORS
Amount:
Frequency:
Caffeine use (coffee/tea/colas)
1 Yes 1 No Time of Day:
Amount:
Frequency:
Alcohol use
1 Yes 1 No
Time of Day:
Amount:
Frequency:
Fiber intake
1 Yes 1 No
Time of Day:
Type of Activity:
Frequency:
Exercise
1 Yes 1 No
Time of Day
G. TOILETING PATTERN AND PRODUCT USE
Day Evening Night
Toileting pattern 1 Toilet
1 Commode
1 Urinal
1 Bed pan
1 Toilet
1 Commode
1 Urinal
1 Bed pan
1 Toilet
1 Commode
1 Urinal
1 Bed pan
Frequency of Toileting
Identify type of pads, briefs or other incontinent products worn including size
H. ABILITIES
Cognitive Y N Comments
Aware of urge to void and defecate
Aware of the urge to defecate
Socially aware of appropriate place to pass urine/stool
Able to find the toilet
Able to understand reminders or prompts
Aware of when wet and/or urine is being passed
Motivated to be continent
Preferences about toileting
Aware of the risk factors related to not emptying bladder and bowel completely and regularly and the importance of doing so
I. PHYSICAL ASSESSMENT
Voided Volume Residual Urine
Send for C & S 1 Yes
1 No
Voiding Record Initiated
1 Yes
1 No
Perineum 1 Intact
1 Redness
1 Excoriation
1 Other _______
Bowel Record Initiated
1 Yes
1 No
Unusual Urine Odour 1 Yes
1 No
Discharge Post Voiding
1 Yes
1 No
Unusual Stool Odour 1 Yes
1 No
Discharge Post BM 1 Yes
1 No
J. FLUID & FOOD INTAKE (Obtain from initial bladder and bowel record)
Fluid/food Intake in 24 hours
Type of fluid
Quantity (1 cup=250 mls)
Type of food
Quantity
Breakfast
Mid am
Lunch
Mid pm
Supper
Evening
Night
Total
K. SUMMARY – CONTINENCE STATUS
Bladder
1 Continent
1 Incontinent : 1 Stress UI 1 Urge UI 1 Overflow UI 1 Functional UI
1 Care Plan Initiated/Updated 1 Voiding Record Initiated
1 Referral required:
1 Dietitian 1 Physician 1 OT 1 PT
1 Treatment Options:
1 Prompted Voiding
1 Fluid Intake Changes
1 Caffeine Reduction
1 Intermittent Catheterization
1 Bedside Commode
1 Personal Hygiene
1 Incontinent Product
1 Other: __________________
Bowel
1 Continent
1 Incontinent
1 Care Plan Initiated/Updated
1 Bowel Record Initiated
1 Referral required:
1 Dietitian 1 Physician 1 OT 1 PT
Contributing Factors
1 Urinary Tract Infection
1 Constipation
1 Weight
1 Cognitive – Mini Mental Status Examination (MMSE) Score: ____
1 Fluid Intake
1 Medications
1 Environmental Factors
1 Caffeine Intake
1 Alcohol Intake
1 Mobility
1 Other
L. CONTINENCE CARE PLAN
Problems Identified Interventions
Date of Assessment: __________________________________________ Assessor: _________________________________________________
Addressograph
This Bladder and Bowel Assessment was originally developed by the Northwestern Ontario BPG Continence Initiative and has been revised by the Toronto BPG Working Group.
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Urinary Incontinence Types and Interventions (Adapted from: RNAO, 2005. Orientation Program for Nurses in Long-Term Care Workbook. Toronto, Canada: RNAO) Stress UI Urge UI Overflow UI Functional UI
Cause Failure to store Failure to store Failure to empty Failure to store
Frequency 20% of all cases 50% of all cases 10% of all cases 20% of all cases
Symptoms -Small amount of urine loss frequently when residents coughs, laughs, changes position -Wet during day -Dry at night, no distention
-Large amounts of urine loss frequently “can’t get to bathroom in time” -Wet day and night -No distention
-Small amounts of urine loss frequently -Wet day and night -Distention
-Bladder and sphincter are normal -Wet day and night -No distention
Pathology Weakness of sphincter Result of neurological and/or urological disease
-Female: result of cystocele -Male: result of enlarged prostrate, fecal impaction
Other factors cause incontinence: -Drugs -Environment -Psychological
Prevalence Mostly female Both male and female Both male and female Both male and female
Treatments/ Interventions
-Medications (e.g., Premarin & Entex-LA) -Kegel exercises -Prompted voiding
-Medications (e.g., Ditropan & antibiotics) -Surgery -Bladder training routines -Toileting routines -Prompted voiding
-Medications (e.g., Prazosin & Proscar) -Surgery -Double voiding -Crede maneuver -Bowel maintenance program -Disimpaction
-Medications -Surgery -Environment -Mobility -Psychological -Prompted voiding
Critical Pathway for Urinary Incontinence (Stress, Urge, and Functional Types) (© UNC-CH School of Medicine, Program on Aging & the Division of Social Services, State of North Carolina)
Nursing Diagnosis
Assessment Goals Intervention
Alteration in urinary elimination: urinary incontinence, -Stress -Urge -Functional
-History and physical exam to determine causes, contributing factors to UI. -Record voiding and incontinence pattern 3-day bladder diary. -Assess bladder symptoms. -Assess urine character, odour, colour. -Rule out urinary retention – Post Void Residual (PVR).
-Reduction or resolution of UI episodes. -Incontinence well managed to promote independence, comfort, quality of life. -Prevention of adverse sequela of UI.
Teach resident: -Toileting schedules. -Pelvic muscle exercises. -Urge control. -Appropriate selection and use of absorbent products. -Toileting devices. -Clothing adaptations. -Bowel management.
Alteration in urinary elimination: urinary retention
-Assess and document urinary retention. -Assess resident’s skill in self-management of voiding and catheter use if indicated. -Monitor bladder diary to assess progress with self-care interventions for bladder emptying.
-Schedule of regular bladder emptying and fluid intake. -Utilization of voiding maneuvers and catheterization, as indicated. -Prevention and early recognition of UTI.
Teach resident: -Voiding maneuvers: Crede and double voiding. -Intermittent catheterization. -UTI prevention. -Sign/Symptom of UTI.
Alteration in fluid volume: fluid volume deficit
-Assess fluid intake from bladder diary recorded for 3 days. -Calculate fluid intake goals based on body weight and activity. -Develop fluid hydration protocol.
-Fluid intake adequate for urine dilution, bladder and bowel function, metabolic needs. -Treatment plan is acceptable to resident.
-Teach resident to implement fluid management protocol to meet individual fluid goals.
Alteration in nutritional intake: bladder irritants
-Assess consumption of bladder irritants: caffeine, artificial sweeteners, carbonated drinks, alcohol, spicy foods, milk, acidic juices. -Assess preferences for substitutions for irritants.
-Elimination or titration of bladder irritants. -Substitution of non-irritating beverages of choice.
-Instruct resident on rationale for avoidance of bladder irritants. -Teach resident ways to reduce and eliminate bladder irritants. -Monitor for effect of elimination.
Alteration in bowel elimination: constipation or fecal impaction
-Assess bowel elimination pattern, fibre and fluid intake, activity, and bowel aides.
-Establish regular bowel schedule. -Establish adequate fluid and fibre intake. -Minimize, avoid use of laxatives or enemas. -Reinforce good hygiene-wiping front to back, change after UI.
-Teach resident bowel program with dietary and fluid adjustments and fibre supplementation. -Develop exercise program within capacity of resident. -Augment toileting with knee-chest position using footstool.
Knowledge deficit related to self-care strategies for bladder health promotion
-Assess baseline knowledge of UI and self-care strategies. -Teach self-care strategies to improve or restore continence and bowel function. -Teach early recognition of UI-related problems: UTI, dermatitis, fecal impaction, urinary retention. -Teach self-monitoring of medication for UI, therapeutic, side and adverse effects.
-Resident describes causes and contributing factors to UI and bowel dysfunction. -Resident demonstrates effective self-care behaviours for urinary and bowel function.
-Instruct resident about UI status and rationale for interventions. -Modify interventions to allow for resident to implement gradually. -Set short term goals. -Reinforce resident behaviours that are health-promoting.
Self-care deficit
-Assess need for skill training to promote independence in toileting, e.g., exercises or physical therapy. -Assess need for equipment to promote independence in toileting, e.g., bedside commode, urinal, external devices. -PT/OT consults to assess need for muscle strengthening/ADL skill training for ambulation, transfer, or use of devices.
-Adaptive equipment and devices are acceptable, feasible, and appropriate for resident’s needs. -Resident achieves highest level of physical function with exercise and rehabilitation therapies. -Resident assisted to achieve maximum independence in toileting skills.
-Select and instruct resident in use of adaptive equipment or devices. -Counsel resident about personal goal-setting related to toileting and continence.
Alteration in skin integrity: urine contact dermatitis
-Assess skin integrity for inflammation, maceration, infection, abrasion, and breakdown. -Asses resident’s usual hygiene pattern. -Assess absorbent product usage for adequacy and appropriateness.
-Skin remains intact. -Absorbent product usage is appropriate for amount and frequency of urine loss. -Absorbent product is acceptable to the resident.
-Individualize skin care. -Monitor for sign/symptom of yeast, urine dermatitis. -Barrier ointment for fecal incontinence.
Alteration in urinary elimination: urinary tract infection
-Assess for signs/symptoms of UTI. -Assess fluid intake and voiding pattern. -Assess intake and output. -Assess bowel pattern for impaction, constipation, fecal incontinence.
-Resident is free of UTI. -Early recognition of signs/symptoms of UTI and urosepsis. -Prompt treatment of UTI.
-Reinforce good hygiene. -Increase fluid intake to 2000 – 4000 a day. -Change pad after each UI episode. -Bowel management. -Vitamin C BID per MD order. -Cranberry juice 8-12 oz. daily. -Re-culture as indicated.
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APPENDIX B: Quarterly Continence Assessment
1. Resident’s Level of Continence (over all shifts in last 90 days) 0. Continent – Completely or usually continent. Bladder and/or bladder incontinent once a
week or less. 1. Potential to be Continent – Sudden increase in incontinence or occasionally incontinent
- bladder incontinent 2 or more times per week but not daily. Bowel incontinent less than once per week.
2. Incontinent – Bladder incontinent on a daily basis. Bowel incontinent all or almost all of the time.
Regular – at least one BM every 3 days
Fecal Impaction
2. Bowel Elimination Pattern
Constipation Diarrhea Adequate fluids & fibre Suppositories 3. Bowel Continence Plan Toileting routine Laxative
No change Improved
4. Changes in Bowel Continence (BC)
Resident’s BC has changed as compared to status 90 days ago or since last assessment Deteriorated Continent Urinary tract infection 5. Bladder Control Pattern Leaks/dribbles/ Toilet/commode/urinal Pads/briefs Scheduled toileting Catheter
6. Bladder Continence Plan
Bladder retraining Ostomy No change Improved
7. Changes in Urinary Continence (UC)
Resident’s UC has changed as compared to status 90 days ago or since last assessment Deteriorated
(adapted from Centers for Medicare and Medicaid Minimum Data Set (MDS) 2002 http://new.cms.hhs.gov/NursingHomeQualityInits/downloads/MDS20MPAF.pdf.) Date of Assessment__________________ Assessor____________________________________
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APPENDIX C: Voiding/Fluid Record
VOID = Amount measured Intake: type of fluid and amount D = Dry Juice glass = 120 ml WS = Wet small Water glass = 180 ml WM = Wet medium Tea cup = 180 ml WL = Wet large Soup bowl = 125 ml
DAY 1 DAY 2 DAY 3 Date Date Date
TIME VOID WET FLUIDS VOID WET FLUIDS VOID WET FLUID S 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 12:00 AM 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM TOTAL
*Please check resident q2h
Addressograph
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APPENDIX D: 7-Day Bowel Record
IDENTIFICATION
Resident
Start Date
End Date
Date Time of BM
Description of BM Toilet or Commode used ( √)
Incontinent (√)
Bowel Protocol Items Given (Natural Stimulant, Laxative, Suppository, Enema)
Adapted from: Ontario Association of Non-Profit Homes and Services for Seniors. (2005). A Resource Guide for Long Term Care Homes: Skin and Wound Care, Continence Care, Nutrition and Hydration. Woodbridge, Canada: Ontario Association of Non-Profit Homes and Services for Seniors.
24
APPENDIX E: Classification of Laxative Therapies
Class Examples Site of Action Mechanism of Action
Osmotic • Magnesium hydroxide (saline osmotic)
• Lactulose
• Sorbitol
Small and large intestine Attract/retain water in intestinal lumen increasing intraluminal pressure
Irritant or peristaltic stimulant
• Senna
• Bisacodyl
• Danthron
• Cascara
Colon Has a direct action on mucosa, stimulates myenteric plexus, and alters water and electrolyte secretion
Bulk or hydrophilic • Plantain derivatives
• Methylcellulose
• Psyllium
• Ispaghula
• Dietary bran
• Celandrin
• Alovera
Small and large intestine Holds water in stool and mechanical distention
Surfactant or softener or wetting agents
• Docusate
• Poloxalkol
Small and large intestine Softens stool by facilitating admixture of fat and water to soften stool.
Tramonte, Brand, Mulrow, Amato, O’Keefe & Ramirez (as cited in Folden, Backer, Maynard, Stevens, Gilbride, Pires & Jones, 2002)
25
APPENDIX F: Stepwise Approach to Management of Con stipation
Specific Treatment Step 1: Exercise--Fluid--Fibre--Toileting Regimen Psyllium hydrophyllic muculoid (Metamucil)* Step 2: Bulk-Forming Laxatives 5-11 grams (1-2 tsp) OD to TID in 8 oz. fluid (Semla, Belzer & Higbee, 1997) Step 3: Stool Softeners Docusate sodium (Colace)* Step 4: Osmotic Laxatives 100 to 400 mg daily (Semla et al., 1997) -Lactulose (Cephalac) 70% liquid solution
Step 5: Stimulants 30-45 ml OD or BID (Semla et al., 1997) - Sorbital liquid* 15 ml TID, then OD (Sanburg et al., 1996) -Magnesium sulfate* 10-30 mg OD (Semia et al., 1997) Step 6: Suppository Enema Senna (Senokot)* 0.5 to 2 grams OD or BID (Davis, 1991)
-Glycerine suppository* - one rectally PRN (Semla et al., 1997) -Bisacodyl (Dulcolax)* 5-10 mg suppository - one rectally PRN (Semla et al., 1997) -Sodium/Potassium phosphate enema (Fleets)* 133 ml(21.3 grams) instill rectally PRN (Gibson et al., 1995)
*Drugs available over the counter
Sanburg, McGuire & Lee (as cited in Folden et al., 2002)
In combination with Step #1: Day #3 without bowel movement: -Begin at step #2 and proceed through step #5 as needed. Day #4 without bowel movement: -Repeat steps #2 through #5. Day #5 without bowel movement: -Go to step #6. (Gibson, Opalka, Moore, Brady & Mion, 1995)
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APPENDIX G: Glossary of Terms
Constipation (Primary or idiopathic): Associated with immobility or decreased levels of physical activity, inadequate intake of fluids and dietary fibre, failure to respond to the urge to defecate, chronic use of stimulant laxatives, and increased serum progesterone levels in women.
Normal Bowel Elimination: Equal to or less than 3 bowel movements per day to one bowel movement daily or at least every other day; soft, brown, formed stool, equal to or greater than 250 ml to 500 ml, with use of laxatives restricted to stool softeners and/or bulk-forming agents.
Prompted Voiding : A behavioural technique using verbal and physical cues to assist the individual to use the toilet or appropriate receptacle. Prompted voiding is a first-line intervention for some types of urinary incontinence (urge, stress, mixed and functional).
Toileting : The process of encouraging the resident to use some type of containment device in which to void or defecate. The containment device may be the toilet, commode, urinal, bedpan, or some other type of receptacle but does not include briefs. Toileting is for the purpose of voiding and not for just changing briefs.
Urinary Incontinence : Involuntary loss of urine that is sufficient to be a problem, and may present as any of the following types:
Transient incontinence is the urine loss resulting from causes outside of or affecting the urinary system such as acute confusion, infection, atrophic urethritis or vaginitis, medications, psychological conditions, restricted mobility or stool impaction.
Urge incontinence is the involuntary passage of urine occurring soon after a strong sense of urgency to void.
Stress incontinence is a loss of urine with coughing and or sneezing resulting in increased abdominal pressure.
Mixed incontinence is urine loss having features of both stress and urge.
Functional incontinence is urinary leakage associated with inability to access the toilet because of impairment of cognitive and/or physical functioning or an environmental barrier.
Overflow incontinence is the involuntary loss of urine associated with bladder over-distention. Total incontinence is a continuous and upredictable loss of urine.
Total incontinence is a continuous and predictable loss of urine.
